Provider Demographics
NPI:1275600397
Name:MERRILL, LISA MARIE (MS,RD)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:MARIE
Last Name:MERRILL
Suffix:
Gender:F
Credentials:MS,RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3341 22ND ST
Mailing Address - Street 2:
Mailing Address - City:WYANDOTTE
Mailing Address - State:MI
Mailing Address - Zip Code:48192-6012
Mailing Address - Country:US
Mailing Address - Phone:734-502-8264
Mailing Address - Fax:734-362-7501
Practice Address - Street 1:3939 VAN HORN RD
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:MI
Practice Address - Zip Code:48183-4013
Practice Address - Country:US
Practice Address - Phone:734-502-8264
Practice Address - Fax:877-287-7216
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI804989133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered